Maternal Health Care in Nepal: Trends and Determinants · 1 INTRODUCTION ... Institutional Delivery, and PNC Check-up within 7 ... Figure 2 Trends in four or more antenatal care visits,

DHS Further Analysis Reports No. 118

Maternal Health Care in Nepal:Trends and Determinants

DHS Further Analysis Reports No. 118

Maternal Health Care in Nepal:

Trends and Determinants

Krishna Kumar Aryal1

Sharad K Sharma2

Mukti Nath Khanal3

Bihungum Bista4

Shiv Lal Sharma2

Shambhu Kafle5

Mona Mehta Steffen6

ICF

Rockville, Maryland, USA

January 2019

1 DFID/NHSP3/MEOR, Abt Associates

2 Department of Health Services, Ministry of Health and Population, Nepal 3 Population Division, Ministry of Health and Population, Nepal

4 Nepal Health Research Council 5 Health Coordination Division, Ministry of Health and Population, Nepal

6 The DHS Program, ICF

Corresponding author: Krishna Kumar Aryal, DFID Nepal Health Sector Programme 3 (NHSP3),

Monitoring, Evaluation and Operational Research (MEOR) Project, Abt Associates, Lalitpur-10,

Lalitpur, Nepal; phone: +977 9851123730; email: [email protected].

Ministry of Health

and Population

Acknowledgments: The authors would like to thank DFID Nepal for its support and technical

assistance in producing this report. We would like to sincerely acknowledge the support from

Joseph James (Abt Britain), Scott Roantree (Abt Britain), and Peter Godwin

(DFID/NHSP3/MEOR Project) to produce this report. Special thanks are extended to Dr.

Sharad K Sharma and Mr. Mukti Nath Khanal from MoHP for steering the overall report write

up. We also extend our gratitude to Tom Fish (ICF) for creating a comparable Province indicator

for the 2011 Nepal DHS survey, and to Kerry MacQuarrie (Avenir Health) and Jennifer

Yourkavitch (ICF) for their assistance with the tables and graphics in the report. We further

express gratitude to the reviewers of this study, Lindsay Mallick (Avenir Health), Sabita

Tuladhar and Shilu Adhikari (USAID), and Punya Paudel (Family Welfare Division/MoHP).

Editor: Diane Stoy

Document Production: Joan Wardell and Cynthia Kramer

This study was carried out with support provided by the United States Agency for International

Development (USAID) through The DHS Program (#AID-OAA-C-13-00095). The views

expressed are those of the authors and do not necessarily reflect the views of USAID or the

United States Government. Additional support for this study was provided by the UK

Department for International Development (DFID) through the DFID Nepal Health Sector

Programme 3 (NHSP3), Monitoring, Evaluation and Operational Research (MEOR) Project.

This study is a further analysis of the 2016 Nepal Demographic and Health Survey (2016

NDHS). The 2016 NDHS was implemented by New ERA under the aegis of the Ministry of

Health and Population of Nepal. Funding for the survey was provided by USAID. ICF provided

technical assistance through The DHS Program, a USAID-funded project providing support

and technical assistance in the implementation of population and health surveys in countries

worldwide.

Additional information about the 2016 NDHS may be obtained from the Ministry of Health and

Population, Ramshahpath, Kathmandu; telephone: +977-1-4262543/4262802; internet:

http://www.mohp.gov.np; and New ERA, Rudramati Marg, Kathmandu, P.O. Box 722,

Kathmandu 44600, Nepal; telephone: +977-1-4413603; email: [email protected]; internet:

http://www.newera.com.np.

The DHS Program assists countries worldwide in the collection and use of data to monitor and

evaluate population, health, and nutrition programs. Additional information about The DHS

Program can be obtained from ICF, 530 Gaither Road, Suite 500, Rockville, MD 20850 USA;

telephone: +1 301-407-6500, fax: +1 301-407-6501, email: [email protected], internet:

www.DHSprogram.com.

Recommended citation:

Aryal, Krishna Kumar, Sharad K. Sharma, Mukti Nath Khanal, Bihungum Bista, Shiv Lal

Sharma, Shambhu Kafle, and Mona Mehta Steffen. 2019. Maternal Health Care in Nepal:

Trends and Determinants. DHS Further Analysis Reports No. 118. Rockville, Maryland, USA:

ICF.

iii

TABLE OF CONTENTS

TABLES .................................................................................................................................................. v

FIGURES .............................................................................................................................................. vii

FOREWORD .......................................................................................................................................... ix

ACKNOWLEDGMENTS ........................................................................................................................ xi

ABSTRACT.......................................................................................................................................... xiii

ACRONYMS AND ABBREVIATIONS ................................................................................................. xv

1 INTRODUCTION ........................................................................................................................ 1

1.1 Objectives ..................................................................................................................... 2

1.2 Conceptual Framework ................................................................................................. 2

2 DATA AND METHODS ............................................................................................................. 5

2.1 Data ............................................................................................................................... 5

2.1.1 Number of women included in the analysis ..................................................... 5

2.2 Variables Included in This Study ................................................................................... 5

2.3 Data Analysis ................................................................................................................ 7

3 TRENDS IN FOUR ANC VISITS, INSTITUTIONAL DELIVERY, AND PNC CHECK-UP

WITHIN 7 DAYS ........................................................................................................................ 9

4 ANTENATAL CARE ................................................................................................................ 11

4.1 Women Completing Four ANC Visits for Their Last Pregnancy by Background

and Contextual Characteristics ................................................................................... 11

4. 2 Women Completing Four ANC Visits for Their Last Pregnancy by Other

Variables (Health Care Access, Women’s Characteristics) ........................................ 13

4.3 Determinants of Four ANC Visits per Protocol for Their Last Pregnancy ................... 15

5 INSTITUTIONAL DELIVERY ................................................................................................... 19

5.1 Women Delivering Their Last Child in a Health Facility by Background and

Contextual Characteristics .......................................................................................... 19

5.2 Women Delivering Their Last Child in a Health Facility by Other Variables

(Health Care Access, Women’s Characteristics) ........................................................ 21

5.3 Determinants of Institutional Delivery ......................................................................... 24

6 POSTNATAL CARE ................................................................................................................ 27

6.1 Women with a PNC Check-up within 7 Days by Background and Contextual

Characteristics ............................................................................................................ 27

6.2 Women with a PNC Check-up within 7 Days by Other Variables (Health Care

Access, Women’s Characteristics) ............................................................................. 29

6.3 Determinants of PNC Check-up within 7 Days ........................................................... 32

7 DISCUSSION ........................................................................................................................... 35

7.1 Trends of Four ANC Visits, Institutional Delivery, and PNC Check-up within 7

Days ............................................................................................................................ 35

7.2 Four ANC Visits ........................................................................................................... 36

7.3 Institutional Delivery .................................................................................................... 37

7.4 Postnatal Check-up ..................................................................................................... 38

7.5 Conclusion .................................................................................................................. 38

7.6 Recommendations and Policy Implications ................................................................ 39

7.6.1 Policy level ..................................................................................................... 39

7.6.2 Program/implementation level ....................................................................... 39

iv

REFERENCES ...................................................................................................................................... 41

APPENDIX ............................................................................................................................................ 43

v

TABLES

Table 1 List of variables and their operational definitions ................................................. 6

Table 2 Percentage of women who had four antenatal care visits per protocol

during their most recent pregnancy by background characteristics, Nepal

DHS 2016 .......................................................................................................... 13

Table 3 Percentage of women who had four antenatal care visits per protocol

during their most recent pregnancy by additional characteristics, Nepal

DHS 2016 .......................................................................................................... 14

Table 4 Logistic regression of women who had four antenatal care visits per

protocol during their most recent pregnancy, Nepal DHS 2016 ........................ 16

Table 5 Percentage of women who delivered their last child in a health facility by

background characteristics, Nepal DHS 2016 ................................................... 21

Table 6 Percentage of women who delivered their last child in a health facility by

additional characteristics, Nepal DHS 2016 ...................................................... 22

Table 7 Logistic regression of women who delivered their last child in a health

facility, Nepal DHS 2016 .................................................................................... 25

Table 8 Percentage of women with a postnatal check-up within 7 days of delivery,

among women with a live birth in the past 2 years, by background

characteristics, Nepal DHS 2016 ....................................................................... 29

Table 9 Percentage of women with a postnatal check-up within 7 days of delivery,

among women with a live birth in the past 2 years, by additional

characteristics, Nepal DHS 2016 ....................................................................... 30

Table 10 Logistic regression of women with a postnatal check-up within 7 days of

delivery, among women with a live birth in the past 2 years, Nepal DHS

2016 ................................................................................................................... 33

vii

FIGURES

Figure 1 Conceptual framework for analyzing determinants of four antenatal

care visits per national protocol ........................................................................... 3

Figure 2 Trends in four or more antenatal care visits, institutional delivery,

postnatal check-up, and all three outcomes, Nepal DHS 2011-2016 .................. 9

Figure 3 Four antenatal care visits per national protocol by household wealth

quintile, Nepal DHS 2016................................................................................... 11

Figure 4 Four antenatal care visits per national protocol by province, Nepal DHS

2016 ................................................................................................................... 12

Figure 5 Four antenatal care visits per national protocol by birth order, Nepal DHS

2016 ................................................................................................................... 15

Figure 6 Institutional delivery by women’s education, Nepal DHS 2016 ......................... 19

Figure 7 Institutional delivery by household wealth quintile, Nepal DHS 2016 ................ 20

Figure 8 Institutional delivery by province, Nepal DHS 2016 ........................................... 20

Figure 9 Institutional delivery by four antenatal visits per national protocol, Nepal

DHS 2016 .......................................................................................................... 23

Figure 10 Institutional delivery by birth preparedness, Nepal DHS 2016 .......................... 24

Figure 11 Postnatal check-up by household wealth quintile, Nepal DHS 2016 ................. 27

Figure 12 Postnatal check-up by province, Nepal DHS 2016 ............................................ 28

Figure 13 Postnatal check-up by place of delivery, Nepal DHS 2016 ............................... 31

Figure 14 Postnatal check-up by advice for postnatal check-up, Nepal DHS 2016 .......... 32

Appendix Figure A1 Conceptual framework for analyzing determinants of place of delivery ............ 43

Appendix Figure A2 Conceptual framework for analyzing determinants of PNC check-up within

7 days................................................................................................................. 43

ix

FOREWORD

The 2016 Nepal Demographic and Health Survey (NDHS) is the fifth nationally representative

comprehensive survey conducted as part of the worldwide Demographic and Health Surveys (DHS)

Program in the country. The survey was implemented by New ERA under the aegis of the Ministry of

Health and Population (MoHP). Technical support for this survey was provided by ICF, with financial

support from the United States Agency for International Development (USAID) through its mission in

Nepal, and support for report production from the United Nations Population Fund (UNFPA).

The standard format of the survey final report included only a descriptive presentation of findings and

trends, and did not include analytical methods that can ascertain the significance of change and

association among variables. Although largely sufficient, the final report is limited, particularly in

providing answers to “why” – answers that are essential in reshaping important policies and programs.

After the dissemination of the NDHS 2016, the MoHP and its partners convened and agreed on key

areas that are necessary for assessing progress, gaps, and determinants in high-priority public health

programs being implemented by the MoHP. In this context, seven further analysis studies have been

conducted by technical professionals from the MoHP and its partners who work directly on the given

areas, with technical support and facilitation from research agencies.

The primary objective of the further analysis of the 2016 NDHS is to provide more in-depth knowledge

and insights into key issues that emerged from the survey. This information provides guidance for

planning, implementing, refocusing, monitoring, and evaluating health programs in Nepal. The long-

term objective of the further analysis is to strengthen the technical capacity of local institutions and

individuals for analyzing and using data from complex national population and health surveys to better

understand specific issues related to country need.

The further analysis of the 2016 NDHS is the concerted effort of many individuals and institutions, and

it is with great pleasure that I acknowledge the work involved in producing this useful document. The

participation and cooperation of the members of the Technical Advisory Committee in the different

phases of the survey are highly valued. I would like to extend my appreciation to USAID/Nepal for

providing financial support for the further analyses and to the UK Department for International

Development (DFID) for additional support it provided through the DFID Nepal Health Sector 3

(NHSP3), Monitoring Evaluation and Operational Research (MEOR) project. I would also like to

acknowledge ICF for its technical assistance at all stages. My sincere thanks also go to the New ERA

team for the overall management and coordination of the entire process. I would also like to thank the

Public Health Administration Monitoring and Evaluation Division, as well as the Policy Planning and

Monitoring Division, MoHP, for their efforts and dedication to the completion of this further analysis

of the 2016 NDHS.

Dr. Pushpa Chaudhary

Secretary

Ministry of Health and Population

xi

ACKNOWLEDGMENTS

The further analysis of the 2016 NDHS was conducted under the aegis of the Public Health

Administration Monitoring and Evaluation Division (PHAMED) of the Ministry of Health and

Population (MoHP). The United States Agency for International Development (USAID) provided

financial support, with technical assistance provided by ICF. Support for report production was provided

by the United Nations Population Fund (UNFPA). The UK Department for International Development

(DFID) provided additional support to this study through the DFID Nepal Health Sector 3 (NHSP3),

Monitoring Evaluation and Operational Research (MEOR) project. Overall coordination, facilitation,

administration, and logistic support were provided by New ERA, a local research firm with extensive

experience in conducting similar studies. The secondary analysis of the 2016 NDHS data has been

conducted by technical professionals from the MoHP and Department of Health Services, USAID, and

other partners who work directly on the given areas, with technical support and facilitation from ICF

and New ERA.

I would like to express my deep appreciation for the contributions of many different stakeholders and

for their valuable input in the various phases of the study and the final report. My sincere gratitude goes

to all members of the National Monitoring and Evaluation Technical Advisory Group at MoHP for their

valuable input. I appreciate the leadership of Mr. Giri Raj Subedi, Sr. Public Health Administrator, and

entire team of the Policy Planning and Monitoring Division, PHAMED, and the Child Health Division

for their contributions during the different phases of the study.

My special gratitude goes to the authors, Dr. Krishna Kumar Aryal, Dr. Sharad K. Sharma, Mr. Mukti

Nath Khanal, Mr. Bihungum Bista, Mr. Shiv Lal Sharma, Mr. Shambhu Kafle, and Ms. Mona Mehta

Steffen, for their hard work in completing this report. I would also like to express my deep appreciation

to the peer reviewers, Ms. Lindsay Mallick (Avenir Health), Dr. Shilu Adhikari (USAID), and Dr. Punya

Paudel (Family Welfare Division/MoHP), for their time and efforts.

The technical support provided by ICF is highly appreciated and acknowledged. My special thanks go

to Ms. Mona Mehta Steffen and Dr. Kerry MacQuarrie for their technical support throughout the period.

My appreciation goes to the staff of New ERA, Mr. Yogendra Prasai, and the entire team of New ERA

for excellently managing the further analysis activities.

Dr. Bikash Devkota

Chief, Policy Planning and Monitoring Division

Ministry of Health and Population

xiii

ABSTRACT

Despite the longstanding efforts of the Ministry of Health and Population (MoHP) in Nepal to promote

maternal and neonatal health (MNH), progress has been slow for MNH service use. This analysis aimed

to identify determinants of maternal health care use: antenatal care (ANC) visits, institutional delivery,

and postnatal care (PNC) check-up. We analyzed 2011 and 2016 Nepal Demographic and Health

Surveys (NDHS) data to illustrate the trend of these three outcome variables, and 2016 NDHS data

alone for determinants of the outcome variables. The number of women included in the analysis was

1,440 for ANC, 1,478 for place of delivery, and 718 for PNC. We used descriptive and inferential

statistics and presented the results as proportions and adjusted odds ratios.

Since 2011, we observed a substantial increase in the proportion of women with four ANC visits and

institutional delivery, but only a small increase in PNC check-up. Lower birth order was associated with

the ANC visits. Better education, completion of four ANC visits, and birth preparedness were associated

with institutional delivery. Having institutional delivery and receiving advice for PNC check-up was

associated with PNC check-up. We found an association of all the outcome variables with wealth

quintile and province.

These findings suggest that women marginalized by geography, wealth, and education are less likely to

access maternal health care. To achieve the goals of increasing the institutional delivery rate to 70%,

and of increasing ANC visits and PNC check-up to 90% by 2020, more focused interventions, targeting

the underserved and most marginalized population, are required.

KEY WORDS: antenatal care; institutional delivery; postnatal care; determinants; Nepal

xv

ACRONYMS AND ABBREVIATIONS

ANC antenatal care

aOR adjusted odds ratio

BCC behavior change communication

CI confidence interval

DHS Demographic and Health Survey

DoHS Department of Health Services

FCHV female community health volunteer

HDI Human Development Index

IEC information, education, and communication

MMR maternal mortality ratio

MoHP Ministry of Health and Population

MPI Multidimensional Poverty Index

OR odds ratio

NDHS Nepal Demographic and Health Survey

NHSP2 Nepal Health Sector Programme-2

NHSP2 IP Nepal Health Sector Programme-2 Implementation Plan

PHAMED Public Health Administration Monitoring & Evaluation Division

PNC postnatal care

PSU primary sampling unit

SBA skilled birth attendant

SDG Sustainable Development Goal

USAID United States Agency for International Development

WHO World Health Organization

1

1 INTRODUCTION

Nepal is a country with a very high maternal mortality ratio (MMR) (258 per 100,000 live births), which

is higher than its South Asian neighbors such as India (174), Bhutan (148), Bangladesh (176), Myanmar

(178), Pakistan (178), and Sri Lanka (30) (WHO et al. 2015). Although there has been a reduction in

pregnancy-related mortality in Nepal from 543 deaths/100,000 live-births in 1996 to 259

deaths/100,000 in 2016 (Ministry of Health, New ERA, and ICF 2017), there is much more to achieve.

Receiving antenatal care (ANC) on specified months as per national protocol, delivering at health

institutions or being assisted by skilled birth attendants (SBA) at health institutions and at home, and

receiving postnatal care (PNC) are vital to preventing maternal and newborn deaths. Nepal is a signatory

to the Sustainable Development Goals (SDGs), which have set ambitious targets for the country to

reduce the MMR to 70 per 100,000 live births and neonatal mortality to 12 per 1,000 live births, and to

achieve coverage of 90% for four ANC visits, institutional delivery, SBA delivery, and three PNC

check-ups by 2030 (National Planning Commission 2017).

Although the rate has been stagnant over the last decade, there has been some decline in the neonatal

death rate (21 per 1,000 live births) in 2016 compared to 33 per 1,000 live births in 2011 (Ministry of

Health, New ERA, and ICF 2017). However, further improvement is needed to meet the 2030 target.

Along with the targets for reducing maternal and neonatal mortality, there are also targets for increasing

the coverage of essential services related to pregnancy and childbirth that can help achieve the mortality

targets. Despite the longstanding efforts of the Ministry of Health and Population (MoHP) to promote

safer pregnancy and childbirth, there has not been satisfactory progress in increasing the proportion of

four ANC visits, institutional delivery, and PNC, which remain at 59%, 57%, and 57% respectively for

the year 2016 (Ministry of Health, New ERA, and ICF 2017). There is a similar proportion (55%) of

institutional delivery shown in the health facility data from the Department of Health Services (DoHS)

(Department of Health Services 2018).

Nepal has been implementing its safe motherhood program since 1997 with the broad aims of reducing

maternal and neonatal morbidity and mortality, and improving maternal and neonatal health. This

program includes strategies focused on birth preparedness, ANC check-ups, and institutional delivery

that reduce the risks of complications during pregnancy and childbirth and address factors associated

with mortality and morbidity (Department of Health Services 2018). In 2005, Nepal introduced the

Aama Program (Maternity Incentive Scheme) which aims to reduce financial barriers for women who

seek institutional delivery (Aryal and Bhatt 2014). Under the current Aama program, Nepalese women

who deliver in a health facility are given a cash incentive of Nepali Rupees (NRs) 3,000 (mountain

districts), NRs 2,000 (hill districts), and NRs 1,000 (Terai districts), with an additional NRs 800 to those

women who complete four ANC visits per national protocol (Family Health Division 2018).

In addition to cash incentives, the Aama program also provides free delivery, essential newborn care,

and care for sick neonates (Department of Health Services 2018). The MoHP in Nepal recommends

four ANC visits at the 4th month (12-16 weeks of gestation), 6th month (20-24 weeks of gestation), 8th

month (28-32 weeks of gestation), and 9th month (36-40 weeks of gestation) (Family Health Division

2016). The World Health Organization (WHO) has changed its earlier recommendation of four ANC

visits to a minimum of eight ANC contacts in its 2016 WHO ANC model. This includes the first contact

in the first trimester (up to 12 weeks of gestation), two contacts in second trimester (20 and 26 weeks

of gestation) and five contacts in the third trimester (30, 34, 36, 38 and 40 weeks of gestation) (World

Health Organization 2016). In addition, three PNC check-ups are recommended to reduce maternal and

2

neonatal morbidity and mortality: the first within 24 hours of delivery, the second on the 3rd day, and

the third on the 7th day of delivery (Department of Health Services 2018).

This further analysis has three outcome variables: four ANC visits as per national protocol in the 4th,

6th, 8th, and 9th month of pregnancy; institutional delivery; and PNC check-ups within 7 days for all

women during their last pregnancy. The 2016 NDHS dataset allowed us to analyze the PNC check-up

within 7 days without possibility of analyzing three check-ups in the specified time in the national

protocol: the first within 24 hours, the second on the 3rd day, and the third on the 7th day (Department

of Health Services 2018).

Using data from the 2016 NDHS, we examine determinants of three components of maternal health

care: four ANC visits as per protocol, institutional delivery, and PNC check-up within 7 days. The

results provide guidance for interventions that are needed for reaching the ambitious targets of

improving essential maternal health services and reducing maternal and neonatal mortality.

1.1 Objectives

With an overall objective of identifying the determinants of maternal health care service utilization in

Nepal, we specifically aim to identify:

• Factors that affect the completion of four ANC visits as per protocol

• Determinants of delivery in health facility

• Factors associated with PNC check-ups within 7 days

1.2 Conceptual Framework

We have adopted the framework of health-care-seeking behavior used by Kebede et al. in their research

on institutional delivery service utilization (Kebede, Hassen, and Nigussie Teklehaymanot 2016) to

develop the conceptual framework for all three outcome variables: four ANC visits (Figure 1),

institutional delivery (Appendix Figure A1), and PNC check-up within 7 days1 (Appendix Figure A2).

This framework incorporated the predisposing, enabling, and need factors of health-seeking behavior

that closely matched our requirements for analyzing the determinants of maternal health care utilization.

In addition to the three factors, we considered the geographical regions (provinces) and urban versus

rural residence as contextual variables in the analysis. This study uses the nomenclature Province 1 –

Province 7, since these are the province names that were in effect at the time of the 2016 survey.2

1Analyses of DHS data typically examine PNC check-up within 2 days. The Nepal national protocol

recommends three PNC check-ups within 7 days. However, we analyze one (or more) PNC check-ups

within 7 days because the NDHS does not record data on the number of PNC check-ups in that time

period. 2 Province 4 has since changed its name to Gandaki Province (July 2018), Province 6 to Karnali

Province (February 2018), and Province 7 to Sudurpashchim Province (September 2018). The

remaining four provinces have not adopted permanent names as of the time of this publication.

3

Figure 1 Conceptual framework for analyzing determinants of four antenatal care visits per national protocol

Contextual factors

Geographical regions (province) Residence – urban rural

Predisposing factors

Women’s age at last birthWomen’s educationCaste/ethnicityHusband’s educationWealth indexWomen’s empowermentDomestic violence

Enabling factors

Exposure to health programs in mediaDistance to health facilityProblem in health care access

Need factors

Wanted pregnancyBirth order number

4 ANC Visits[1]

[1] The national protocol recommends ANC v isits in the 4th, 6th, 8th, and 9th months of pregnancy .

5

2 DATA AND METHODS

2.1 Data

We used the 2011 and 2016 NDHS data to analyze the three outcome variables. The NDHS, like other

DHS surveys, is a nationally representative survey that provides current data on basic demographic and

health indicators related to access to health services, some health behaviors, and health outcomes. The

2016 NDHS sampled 11,473 households from 383 clusters by using a two-stage sampling in rural areas

and a three-stage sampling in urban areas. From the 11,040 households interviewed, there were 13,089

eligible women, out of whom 12,862 women were interviewed (99% response rate). Details on survey

design, sample design, and survey instruments are described in the full 2016 NDHS report (Ministry of

Health, New ERA, and ICF 2017). The 2011 NDHS sampled 11,353 households from 289 clusters with

a two-stage sampling. Interviews were completed in 10,826 households and with 12,674 women.

Details on survey design, sample design, and survey instruments are also described in the full 2011

NDHS report (Ministry of Health and Population, New ERA, and Inc. 2012).

To study the predictors of care, we selected a subset of 4,006 women who had a live birth in the 5 years

before the 2016 survey, including the most recent birth, and who were among the 12,862 women

interviewed in the survey. One of the variables of interest for this analysis was experience of domestic

violence by women. We further restricted this analysis to the subsample of women who were

interviewed on the domestic violence module in the survey.

2.1.1 Number of women included in the analysis

For examining determinants of care using 2016 data, 1,538 women met both criteria: had a live birth in

the previous 5 years and completed the domestic violence module. In addition, since the ANC analysis

included completion of four ANC visits, we included women with at least one ANC visit. This resulted

in a total sample of 1,440 woman for ANC-related analysis. With place of delivery, we excluded women

who responded that the place of delivery was India or other countries, which resulted in a final sample

of 1,478 woman for this subset. With the PNC analysis, there were 1,970 women who both had a live

birth in the previous 2 years and completed the domestic violence module. The total sample for PNC-

related analysis was 718 women.

2.2 Variables Included in This Study

Table 1 presents the study variables that include background, access to media and health care, women’s

empowerment and domestic violence, and pregnancy-related criteria. ANC visit variable is defined as

four or more ANC visits in the trend analysis using 2011 and 2016 NDHS data, whereas this is defined

as having four ANC visits in the specified months per national protocol for the purpose of determinants

analysis using 2016 NDHS data.

6

Table 1 List of variables and their operational definitions

Dependent Variables Definition 2011 2016

Completion of four ANC visits1

Whether or not women had made ANC visit at 4, 6, 8, and 9 months among those with at least one ANC visit N = 3,468 N = 3,754

Place of delivery Home, institution/health facility N = 4,012 N = 3,847

PNC check-up within seven days Whether the woman received PNC check-up for her last child birth within seven days N = 1,798 N = 1,961

All three Women completing all the above three variables N = 1,552 N = 1,804

Background variables Definition Categories

Age at last birth Completed age of the women at the time of last child birth

1) <20 Years 2) 20-24 Years 3) 25-29 Years 4) 30-49 Years

Education Level of education classified as per the years of schooling/grades completed

1) No education 2) Basic education (with

incomplete secondary education and below)

3) Higher education (completed secondary or higher)

Caste/ethnicity Ethnic categories that an individual falls into

1) Dalits 2) Muslim 3) Janajati 4) Other Terai 5) Brahmin/ Chhetri

Husband's education Level of education classified by the years of schooling/grades completed

1) No education 2) Basic education (with

incomplete secondary education and below)

3) Higher education (completed secondary or higher)

Household wealth quintile Quintile based on household wealth index score

1) Poorest 2) Poorer 3) Middle 4) Richer 5) Richest

Place of residence Urban and rural 1) Rural 2) Urban

Province Geographical origin of the women

1) Province 1 2) Province 2 3) Province 3 4) Province 4 5) Province 5 6) Province 6 7) Province 7

Access-related variables

Exposure to health programs in media (heard/seen at least 2)

Whether or not the women saw or heard at least two of the following health programs: jana swasthya radio karyakram, janasankhya chetana karyakaram, jeevan chakra tv karyakram, thorai bhaye pugi sari tv karyakram, saathi sanga mann ka kura radio karyakram, bhanchhin ama radio karyakram, bhandai sundai radio karyakram, parivaar niyojan smart banchha jeevan tv/radio karyakram, navi malam tv/radio karyakram

1) No: Not heard or seen at least two programs

2) Yes: Heard or seen at least two programs

Distance to health facility Duration to reach nearest health facility in minutes

1) >30 mins 2) <30 mins

Problem in health care access

Whether or not the women perceived the following as a problem: getting permission to go for treatment (medical help), getting money needed for treatment, distance to health facility, not wanting to go alone to the health facility, concern of no female health provider

1) All five problems 2) Some

3) None

(Continued…)

7

Table 1—Continued

Women's empowerment and domestic violence

Women's empowerment

Whether or not women can refuse sex, women can decide on own health care, and can decide to use contraception

1) No: Women cannot refuse sex, cannot decide on own health care and cannot decide to use contraception

2) Yes: Women can refuse sex, can decide on own health care, and can decide to use contraception

Domestic violence Experienced any spousal violence (emotional, physical or sexual) in last 12 months

1) Yes: Experienced any of the three types of spousal violence

2) No: Not experienced any of the three types of spousal violence

Pregnancy-related variables (Four ANC Visits)

Birth order number Birth order of the last child born

1) 1: First 2) 2: Second 3) 3: Third or higher

Wanted pregnancy Whether the pregnancy of the last child birth was wanted

1) No 2) Yes

Pregnancy-related variables (Institutional delivery)

Four ANC visits as per protocol

Whether or not women had received an ANC visit at 4, 6, 8 and 9 months among those with at least 1 ANC visit

1) Not completed

2) Completed

ANC quality of care

Whether or not women were advised for SBA delivery, for institutional delivery, to look for possible problems with pregnancy, and to get postnatal check-up

1) No: None or some of them

2) Yes: All four aspects

Birth preparedness Whether or not women were prepared with money, food, and clothes as a birth preparation

1) No: None or some of them

2) Yes: All three aspects

Pregnancy-related variables (PNC within 7 days)

Birth order number Birth order of the last child born

1) 1: First 2) 2: Second 3) 3: Third or higher

Wanted pregnancy Whether the pregnancy of the last child birth was wanted

1) No 2) Yes

Four ANC visits per protocol

Whether or not women had received an ANC visit at 4, 6, 8 and 9 months among those with at least one ANC visit

1) Not completed

2) Completed

Place of delivery Place where women delivered their last child 1) Home 2) Institution

Sex of baby Sex of the last child born 1) Girl 2) Boy

Advised PNC check-up Whether or not women were advised to get postnatal check-up

1) No 2) Yes

1 The "Four ANC visits" variable used for the 2016 determinants analysis is as defined above and follows the timings per the national protocol, whereas for the trends analysis the "Four ANC visits" variable used is defined as four or more ANC visits, without the timings specified.

2.3 Data Analysis

The NDHS 2011 and 2016 data sets were used to assess changes over time in the outcome variables.

We carried out bivariate analysis for proportions for each of the three outcome variables by all the

independent variables and examined the difference in proportion using chi square tests. We performed

logistic regression initially using the domestic violence weight, primary sampling unit (PSU), and

stratum variable. Some variables were excluded after the multicollinearity tests. Variables not

significant at the 0.05 level in the bivariate logistic regression were included in the multivariable logistic

regression due to their contextual importance. The final logistic regression model for each of the three

outcome variables included relevant, contextually important independent variables for ANC visits,

institutional delivery, and PNC check-ups. Distribution results are presented, followed by the odds ratio

8

(OR) and adjusted odds ratio (aOR) with 95% confidence intervals (95% CI). In addition, we present

some of the distribution results in figures using significant levels as per chi square tests.

9

3 TRENDS IN FOUR ANC VISITS, INSTITUTIONAL DELIVERY, AND PNC CHECK-UP WITHIN 7 DAYS

We planned to assess changes in the three outcomes from 2011 to 2016. However, since the 2011 ANC

visit data included a different definition, we used four or more ANC visits during the last pregnancy for

examining the change in ANC data from 2011 to 2016. The delivery and PNC variables are presented

for change from the 2011 to the 2016 NDHS, as well as in the determinants analysis of the 2016 NDHS.

Changes in the three variables from 2011 to 2016 are shown in Figure 2. The proportion of women with

four or more ANC visits has increased from 59% in 2011 to 74% in 2016. Similarly, the institutional

delivery rate has increased from 39% in 2011 to 60% in 2016 for the last child born. In comparison to

the ANC visit and place of delivery, the percentage of PNC check-ups within 7 days among women for

their last childbirth has increased only slightly from 56% in 2011 to 59% in 2016. Similarly, the

proportion of women who completed four or more ANC visits, delivered in a health facility, and had a

PNC check-up within 7 days increased from 40% in 2011 to 48% in 2016.

Figure 2 Trends in four or more antenatal care visits, institutional delivery, postnatal check-up, and all three outcomes, Nepal DHS 2011-2016

59.0

39.2

55.5

39.6

73.7

60.2 58.5

47.5

0

10

20

30

40

50

60

70

80

90

100

4+ ANC*** Institutional Delivery*** PNC Checkup All Three**

Pe

rce

nta

ge

2011 2016

*** p<0.001; ** p<0.01; * p<0.05

11

4 ANTENATAL CARE

This section presents the results for determinants analysis for ANC using 2016 NDHS data, starting

with the proportion of women having four ANC visits by background and other independent variables

followed by predictors of four ANC visits.

4.1 Women Completing Four ANC Visits for Their Last Pregnancy by Background and Contextual Characteristics

Table 2 presents the proportion of women who completed four ANC visits for their last pregnancy

during the months (4th, 6th, 8th, and 9th) stipulated in the national ANC protocol by background

characteristics. A slightly lower proportion (53%) of women in the higher age category had completed

four ANC visits compared to other age groups. The proportion of women completing four ANC visits

increased with education, with 76% among the women with higher education. Among the different

ethnic groups, a higher proportion (69%) of Brahmin and Chhetri women had four ANC visits compared

to the other ethnic groups, while other Terai castes had the smallest proportion (41%) of women who

completed the four ANC visits per the national protocol. We found a similar pattern of care-seeking

behavior among women by the education status of their husband, with a higher proportion (71%) of

women whose husband had higher education having completed four ANC visits compared to those with

husbands who had low or no education.

Figure 3 Four antenatal care visits per national protocol by household wealth quintile, Nepal DHS 2016

50.051.9

53.1

64.4

77.8

58.6

0

10

20

30

40

50

60

70

80

90

100

Poorest Poorer Middle Richer Richest Total

Pe

rce

nta

ge

Household wealth quintile***

*** p<0.001; ** p<0.01; * p<0.05The national protocol recommends ANC v isits in the 4th, 6th, 8th, and 9th months of pregnancy .

12

The analysis also showed that ANC-seeking behavior increased with economic status, with 78% of

women in the richest wealth quintile having completed four ANC visits (Figure 3). More women from

urban areas (65%) completed the four ANC visits than the rural women (Table 2), while 70% of women

in Province 4 (Gandaki Province) completed four ANC visits compared to a low of 40% in Province 2

(Figure 4).

Figure 4 Four antenatal care visits per national protocol by province, Nepal DHS 2016

64.5

40.0

67.5 69.6

64.2

44.0

67.9

58.6

0

10

20

30

40

50

60

70

80

90

100

Province 1 Province 2 Province 3 Province 4 Province 5 Province 6 Province 7 Total

Pe

rce

nta

ge

Province***

*** p<0.001; ** p<0.01; * p<0.05

The national protocol recommends ANC v isits in the 4th, 6th, 8th, and 9th months of pregnancy .

13

Table 2 Percentage of women who had four antenatal care visits per protocol during their most recent pregnancy by background characteristics, Nepal DHS 2016

Background Characteristics % N 95% CI

Age at last birth (years) 15-19 60.8 267 53.2-68.0 20-24 58.7 564 53.1-64.1 25-29 60.3 378 54.4-65.9 30-49 52.9 231 43.2-62.4

Education

No education 41.0 441 34.9-47.4 Basic education 60.4 641 55.3-65.3 Higher education 76.2 358 69.4-81.9

Caste/ethnicity1

Dalits 55.3 229 46.5-63.8 Muslim 44.5 69 29.8-60.2 Janajati 62.1 456 55.2-68.7 Other Terai 40.8 187 33.0-49.0 Brahmin/Chhetri 69.0 493 63.2-74.3

Husband's education2


Household wealth quintile

Poorest 50.0 357 43.1-56.9 Poorer 51.9 325 45.4-58.3 Middle 53.1 291 45.6-60.5 Richer 64.4 286 57.4-70.8 Richest 77.8 181 68.3-85.1

Place of residence

Rural 51.0 610 45.6-56.4 Urban 65.0 830 59.4-70.2

Province

Province 1 64.5 221 54.6-73.3 Province 2 40.0 266 32.3-48.1 Province 3 67.5 176 55.2-77.8 Province 4 69.6 151 61.6-76.5 Province 5 64.2 229 56.2-71.4 Province 6 44.0 206 33.7-52.5 Province 7 67.9 191 60.0-74.9

Total 58.6 1,440 54.7-62.4 1 6 cases falling to other category dropped from analysis 2 11 cases excluded from analysis because of nonresponse or don’t know response

4. 2 Women Completing Four ANC Visits for Their Last Pregnancy by Other Variables (Health Care Access, Women’s Characteristics)

Table 3 presents the proportion of women who completed four ANC visits for their last pregnancy

during the months (4th, 6th, 8th, and 9th) stipulated in the national ANC protocol by background

characteristics. A higher proportion of women (70%) who had exposure to at least two health programs

in mass media had four ANC visits compared to those with fewer than two exposures. (52%). The

proportion of four ANC visits was slightly higher (62%) among women who lived less than 30 minutes

distance to a health facility as compared to those who lived more than 30 minutes (52%). Problems in

health care access were measured by how women perceived the following five dimensions: obtaining

permission to go for treatment (medical help), obtaining money needed for treatment, distance to a

health facility, not wanting to go alone to the health facility, and concern about there being no female

health provider. About 47% of women who had a problem with all five aspects completed four ANC

visits in comparison to those who had no problem with any of the five aspects (71%).

14

Table 3 Percentage of women who had four antenatal care visits per protocol during their most recent pregnancy by additional characteristics, Nepal DHS 2016

Characteristics % N 95% CI

Access to health care

Exposure to health programs in media (heard/seen at least two)

No 51.6 882 46.8-56.5 Yes 70.4 558 65.7-74.8

Distance to health facility

>30 mins 52.0 487 45.6-58.4 <30 mins 61.5 953 56.9-65.9


All 46.9 268 38.5-55.5 Some 59.0 950 54.6-63.3 None 71.1 222 61.4-79.1

Pregnancy related characteristics

Birth order number

1 68.9 489 63.4-73.9 2 63.0 474 57.0-68.6 3+ 41.2 477 35.1-47.7

Wanted pregnancy

No 52.1 263 42.7-61.3 Yes 60.2 1,177 55.9-64.3


Women's empowerment1

No 57.8 708 52.5-62.9 Yes 60.3 629 55.1-65.3

Domestic violence

Yes 53.6 100 43.8-63.1 No 59.5 1,229 55.6-63.4

Total 58.6 1,440 54.7-62.4

1 103 cases falling short due to missing response

With pregnancy-related characteristics, the proportion of four ANC visits decreased with birth order,

from 69% among women whose last child was the first birth, to 41% among women whose last birth

was the third or higher-order birth (Table 3, Figure 5).

15

Figure 5 Four antenatal care visits per national protocol by birth order, Nepal DHS 2016

Four ANC visits were slightly more common (60%) among women whose last pregnancy was a wanted

pregnancy than those who did not want their last pregnancy (52%) (Table 3). The 2016 NDHS measured

women’s empowerment by three characteristics: if women can refuse sex, if they can decide about their

own health care, and if they can decide to use contraception on their own. The proportion of women

completing four ANC visits among those who were empowered or not was similar. The proportion of

four ANC visits was 60% among women who did not experience domestic violence (any emotional,

physical or sexual violence), which was slightly higher than those who experienced domestic violence

(54%). (Table 3)

4.3 Determinants of Four ANC Visits per Protocol for Their Last Pregnancy

Table 4 presents the results of the bivariate and multivariate binary logistic regressions, which illustrate

the odds of having completed four ANC visits per protocol for women with their pregnancy of the last

child born. After an initial bivariate logistic regression, a multivariate logistic regression was used to

adjust the effects of covariates. Women in the richer wealth quintile had nearly two times (aOR=1.76;

95% CI=1.07-2.89) higher odds of having four ANC visits compared to those in the lowest wealth

quintile. Women in Province 4, Gandaki Province (aOR=2.07; 95% CI=1.10-3.91) and Province 7,

Sudurpashchim Province (aOR=2.54; 95% CI=1.29-5.00) had slightly more than twice the odds of

having four ANC visits as compared to women living in Province 2. The order of birth was also a

significant factor in completing the four ANC visits. Women whose last child was the first birth had

twice higher odds (aOR=1.96; 95% CI=1.15-3.32) and those with second birth order had slightly more

than one-half times higher odds (aOR=1.65; 95% CI=1.09-2.52) of having completed four ANC visits

as compared to those with birth order of third or more.

68.963.0

41.2

58.6

0

10

20

30

40

50

60

70

80

90

100

One Two Three or more Total

Pe

rce

nta

ge

Birth order***

*** p<0.001; ** p<0.01; * p<0.05


16

Table 4 Logistic regression of women who had four antenatal care visits per protocol during their most recent pregnancy, Nepal DHS 2016

Characteristics N OR 95% CI aOR 95% CI

Background Variables

Age at last birth (years)

30-49 231 Ref Ref 15-19 267 1.38 0.84-2.26 0.79 0.41-1.52 20-24 564 1.26 0.81-1.96 0.87 0.52-1.45 25-29 378 1.35 0.90-2.02 1.01 0.64-1.57

Education

No education 441 Ref Ref Basic education 641 2.20*** 1.59-3.03 1.21 0.82-1.79 Higher education 358 4.61*** 2.99-7.12 1.49 0.83-2.66

Caste/ethnicity1

Dalits 229 Ref Ref Muslim 69 0.65 0.32-1.31 0.62 0.25-1.52 Janajati 456 1.32 0.85-2.05 0.76 0.48-1.20 Other Terai 187 0.55* 0.33-0.92 0.61 0.31-1.20 Brahmin/Chhetri 493 1.80* 1.15-2.79 0.99 0.59-1.65




Poorest 357 Ref Ref Poorer 325 1.07 0.76-1.53 1.05 0.71-1.56 Middle 291 1.13 0.77-1.66 1.33 0.83-2.15 Richer 286 1.80** 1.20-2.70 1.76* 1.07-2.89 Richest 181 3.50*** 2.00-6.14 1.61 0.79-3.29

Place of residence

Rural 610 Ref Ref Urban 830 1.78** 1.28-2.47 1.26 0.89-1.79

Province

Province 2 221 Ref Ref Province 1 266 2.73*** 1.61-4.64 1.82 0.96-3.43 Province 3 176 3.12*** 1.68-5.81 1.82 0.88-3.77 Province 4 151 3.43*** 2.11-5.58 2.07* 1.10-3.91 Province 5 229 2.69*** 1.68-4.31 1.69 0.96-2.98 Province 6 206 1.18 0.73-1.90 0.97 0.50-1.88 Province 7 191 3.17*** 1.97-5.12 2.54** 1.29-5.00



No 882 Ref Ref Yes 558 2.23* 1.69-2.93 1.1 0.78-1.54


>30 mins 487 Ref Ref <30 mins 953 1.47* 1.07-2.03 1.27 0.92-1.76


All 268 Ref Ref Some 950 1.63* 1.10-2.41 0.98 0.66-1.45 None 222 2.79*** 1.61-4.79 1.22 0.69-2.14

Pregnancy-related characteristics

Birth order number

3+ 477 Ref Ref 1 489 3.15*** 2.24-4.44 1.96* 1.15-3.32 2 474 2.42*** 1.74-3.38 1.66* 1.09-2.52

Wanted pregnancy

No 263 Ref Ref Yes 1,177 1.39 0.91-2.11 1.33 0.90-1.98

(Continued…)

17

Table 4—Continued




No 708 Ref Ref Yes 629 1.11 0.83-1.49 0.88 0.65-1.20

Domestic violence

Yes 100 Ref Ref No 1,229 1.27 0.86-1.90 1.05 0.73-1.52

*** p<0.001; ** p<0.01; * p<0.05 1 6 cases in “other” category excluded from analysis. 2 11 cases excluded from analysis because of nonresponse or don’t know response. 3 103 cases excluded from analysis due to missing response.

19

5 INSTITUTIONAL DELIVERY

This section presents the results for determinants analysis for institutional delivery using 2016 NDHS

data, starting with the proportion of women delivering in a health facility (institutional delivery) by

background and other independent variables followed by predictors of institutional delivery.

5.1 Women Delivering Their Last Child in a Health Facility by Background and Contextual Characteristics

Table 5 presents the proportion of women who delivered their last child in a health facility by

background and contextual characteristics. About two-thirds (66%) of women younger than age 20 at

last birth delivered their last child at a health facility, whereas this proportion was 48% among women

age 30-49. Compared to women with no education (37%), a larger proportion of women with basic

education (61%) and women with higher education (85%) delivered their last child at a health facility

(Table 5, Figure 6).

Figure 6 Institutional delivery by women’s education, Nepal DHS 2016

With caste/ethnicity, a higher proportion (69%) of the Brahmin/Chhetri caste groups delivered their last

child at a health facility. This proportion was lowest (44%) for other Terai caste groups (Table 5). The

proportion of institutional delivery was higher (77%) among women whose husband had higher

education in comparison to women whose husband had no education (32%) (Table 5).

36.5

61.3

84.9

59.3

0

10

20

30

40

50

60

70

80

90

100

No education Basic education Higher education Total

Pe

rce

nta

ge

Women's education***

*** p<0.001; ** p<0.01; * p<0.05

20

Figure 7 Institutional delivery by household wealth quintile, Nepal DHS 2016

A large proportion (92%) of women in the richest wealth quintile delivered their last child at a health

facility. This was true for only 36% for women in the poorest wealth quintile (Table 5, Figure 7). Around

69% of the urban women delivered at a health facility (Table 5).

Figure 8 Institutional delivery by province, Nepal DHS 2016

36.0

47.7

61.5

69.4

91.5

59.3

0

10

20

30

40

50

60

70

80

90

100


Pe

rce

nta

ge


*** p<0.001; ** p<0.01; * p<0.05

64.4

42.9

73.074.8

59.6

38.1

64.1

59.3

0

10

20

30

40

50

60

70

80

90

100


Pe

rce

nta

ge

Province***

*** p<0.001; ** p<0.01; * p<0.05

21

With respect to geographic differences, the proportion of women delivering in a health facility was more

than 70% in Provinces 3 and 4, while it was as low as 38% in Province 6, Karnali Province (Table 5,

Figure 8).

Table 5 Percentage of women who delivered their last child in a health facility by background characteristics, Nepal DHS 2016

Background Characteristics % N 95% CI


15-19 66.3 267 59.0-72.8 20-24 61.9 557 56.7-66.9 25-29 57.7 402 51.6-63.6 30-49 48.2 252 38.9-57.6

Education


Caste/ethnicity1

Dallits 53.9 231 45.1-62.5 Muslim 47.5 68 29.6-66.1 Janajati 61.7 480 55.0-67.9 Other Terai 44.4 183 35.9-53.3 Brahmin/Chhetri 69.2 510 63.2-74.5





Place of residence

Rural 48.2 634 42.7-53.6 Urban 68.7 844 63.5-73.4

Province


Total 59.3 1,478 55.6-62.9

1 6 cases in “other” category excluded from analysis. 2 14 cases excluded from analysis because of nonresponse or don’t know response.

5.2 Women Delivering Their Last Child in a Health Facility by Other Variables (Health Care Access, Women’s Characteristics)

Table 6 presents the proportion of women who delivered their last child in a health facility (institutional

delivery) by access-related variables. A total of 74% of women exposed to health programs in mass

media (at least two programs) delivered their last child at a health facility as compared to 51% of women

who either did not hear or see health programs in media, or had heard or seen fewer than two media

programs. The proportion of health facility delivery was 65% among women living within less than 30

minutes walking distance to a health facility compared to 48% among women with walking distance

greater than 30 minutes. Problems in health care access were assessed by how women perceive the

following five dimensions: obtaining permission to go for treatment (medical help), obtaining money

22

needed for treatment, distance to health facility, not wanting to go alone to the health facility, and

concern about not having a female health provider. The institutional delivery rate was 75% among

women who had no problems with any of the five components, while it was 60% among those who

perceived some of the components as a problem, and 46% among those women who had problems in

all five components.

Table 6 Percentage of women who delivered their last child in a health facility by additional characteristics, Nepal DHS 2016




No 50.5 908 45.9-55.1 Yes 74.1 570 69.6-78.1


>30 mins 48.0 517 42.0-54.0 <30 mins 64.6 961 60.2-68.9


All 5 problems 46.0 285 39.2-52.7 Some 59.5 969 55.2-63.7 None 75.4 224 67.2-82.0

Pregnancy related characteristics

4 ANC visits as per protocol1

Not completed 42.4 559 37.1-47.8 Completed 74.8 826 70.8-78.4

ANC quality of care2

No 54.6 696 49.6-59.5 Yes 69.6 680 64.5-74.3

Birth preparedness (money, food, clothes)

No 53.1 1,002 48.6-57.5 Yes 73.5 476 68.3-78.1



No 56.5 728 51.2-61.7 Yes 62.3 643 57.6-67.8

Domestic violence

Yes 51.9 219 42.4-61.3 No 60.7 1,259 56.8-64.6

Total 59.3 1,478 55.6-62.9

1 93 cases excluded from analysis due to missing response. 2 102 cases excluded from analysis due to missing response. 3 107 cases excluded from analysis due to missing response.

Among women who completed four ANC visits per national protocol, about 75% delivered at a health

facility as compared to those who did not complete the recommended four ANC visits (42%) (Figure 9,

Table 6).

23

Figure 9 Institutional delivery by four antenatal visits per national protocol, Nepal DHS 2016

The 2016 NDHS measured the ANC quality of care by four different types of advice: if women were

advised about seeking SBA delivery, having an institutional delivery, looking for possible problems

with pregnancy, and obtaining a postnatal check-up. The composite score was categorized as yes for all

four types of advice, and no for some or none of the types of advice. We found that 70% of women who

had fulfilled all four criteria of ANC quality of care delivered their last child in a health facility in

comparison to those who met fewer than four criteria (55%) (Table 6). Similarly, the 2016 NDHS

measured the birth preparedness among the survey respondents with three categories: if women were

prepared with money, food, and clothes as a birth preparation, with responses categorized as YES (all

three) or NO (none or less than three). We found that nearly three-quarters (74%) of those women

prepared with all three aspects delivered their last child in the health facility, compared to those not

prepared or prepared in only few aspects (53%) (Figure 10, Table 6).

42.4

74.8

59.3

0

10

20

30

40

50

60

70

80

90

100

No Yes Total

Pe

rce

nta

ge

4 ANC as per national protocol***

*** p<0.001; ** p<0.01; * p<0.05


24

Figure 10 Institutional delivery by birth preparedness, Nepal DHS 2016

The 2016 NDHS measured women’s empowerment by three characteristics: if women can refuse sex,

if they can decide about their own health care, and if they can decide to use contraception on their own.

A slightly higher proportion of empowered women (62%) delivered their last child in the health facility

than women who were not empowered (57%) (Table 6). Similarly, the proportion of health facility

delivery was slightly higher (61%) among women who didn't face domestic violence (any emotional,

physical, or sexual violence) than women who did (52%) (Table 6).

5.3 Determinants of Institutional Delivery

Table 7 presents the results of the bivariate and multivariate logistic regressions, which illustrate the

odds of delivering at a health facility for the last child borne. After an initial bivariate logistic regression,

a multivariable logistic regression model was used to adjust for the effects of covariates. The analysis

showed a significant association between women’s educational status and utilization of health facility

delivery service. Women who had basic education had one and one-half times higher odds (aOR=1.51;

95% CI=1.00-2.26) and women with higher education had nearly two and one-half times higher odds

(aOR=2.19; 95% CI=1.19-4.04) of giving birth at health institution than those with no education.

Women in the middle (aOR=3.70; 95% CI=2.18-6.28) and the richer (aOR=4.11; 95% CI=2.43-6.96)

wealth quintiles had higher odds of health-facility delivery services than those in the poorest wealth

quintile. Respondents in the richest wealth quintile had 11 times higher odds of delivering at a health

facility than those in the poorest (aOR=11.16; 95% CI=4.70-26.49). Women from Province 4, Gandaki

Province (aOR=2.46; 95% CI=1.26-4.83), and Province 7, Sudurpashchim Province (aOR=2.11; 95%

CI=1.00-4.47), had slightly more than two times higher odds of delivering at a health facility delivery

compared to women in Province 6 (Karnali Province). The analysis revealed that women who have

completed four ANC visits per protocol had two and one-half times higher odds (aOR=2.39; 95%

CI=1.72-3.32) of delivering at a health facility than those who have not completed the visits. Women

53.1

73.5

59.3

0

10

20

30

40

50

60

70

80

90

100

No Yes Total

Pe

rce

nta

ge

Birth Preparedness***

*** p<0.001; ** p<0.01; * p<0.05

25

with birth preparedness had one and one-half times higher odds (aOR=1.58; 95% CI=1.11-2.24) of

delivering at a health facility compared to women who were not prepared.

Table 7 Logistic regression of women who delivered their last child in a health facility, Nepal DHS 2016


Background Variables


30-49 267 Ref Ref 15-19 557 2.11** 1.31-3.39 1.69 0.99-2.90 20-24 402 1.75* 1.14-2.68 1.22 0.75-1.96 25-29 252 1.46 0.99-2.17 0.98 0.61-1.58

Education

No education 480 Ref Ref Basic education 648 2.76*** 1.98-3.85 1.51* 1.00-2.26 Higher education 350 9.79*** 6.28-15.26 2.19* 1.19-4.04

Caste/ethnicity1

Dalits 231 Ref Ref Muslim 68 0.77 0.34-1.76 0.67 0.22-2.01 Janajati 480 1.37 0.87-2.17 0.84 0.51-1.37 Other Terai 183 0.68 0.41-1.12 0.76 0.37-1.54 Brahmin/Chhetri 510 1.91** 1.25-2.92 0.96 0.57-1.61




Poorest 401 Ref Ref Poorer 338 1.62* 1.11-2.36 1.56 0.96-2.55 Middle 283 2.84*** 1.87-4.32 3.70*** 2.18-6.28 Richer 279 4.03*** 2.59-6.26 4.11*** 2.43-6.96 Richest 177 19.23*** 9.65-38.32 11.16*** 4.70-26.49

Place of residence

Rural 634 Ref Ref Urban 844 2.36*** 1.17-3.25 1.42 0.96-2.10

Province

Province 6 222 Ref Ref Province 1 259 2.93*** 1.17-5.03 1.39 0.71-2.73 Province 2 181 1.22 0.70-2.12 0.71 0.30-1.71 Province 3 161 4.40*** 2.31-8.39 1.89 0.96-3.70 Province 4 237 4.83*** 2.52-9.26 2.46** 1.26-4.83 Province 5 231 2.4** 1.39-4.13 1.01 0.54-1.91 Province 7 187 2.89** 1.55-5.40 2.11* 1.00-4.47



No 908 Ref Ref Yes 570 2.80*** 2.14-3.66 1.17 0.80-1.71


>30 mins 517 Ref Ref <30 mins 961 1.98*** 1.47-2.67 1.31 0.87-1.97


All 5 problems 285 Ref Ref Some 969 1.73*** 1.29-2.33 1.1 0.65-1.88 None 224 3.61*** 2.25-5.79 1.07 0.72-1.58

(Continued…)

26

Table 7—Continued



4 ANC visits as per protocol3

Not completed 559 Ref Ref Completed 826 4.03*** 3.04-5.36 2.39*** 1.72-3.32

ANC quality of care4

No 696 Ref Ref Yes 680 1.9*** 1.41-2.57 1.07 0.73-1.55

Birth preparedness (money, food, clothes)

No 1,002 Ref Ref Yes 476 2.44*** 1.84-3.25 1.58* 1.11-2.25



No 728 Ref Ref Yes 643 1.3 0.97-1.75 0.95 0.68-1.32

Domestic violence

Yes 219 Ref Ref No 1,259 1.43 0.95-2.16 1.22 0.77-1.94

* p<0.05; ** p<0.01; *** p<0.001 1 6 cases in “other” category excluded from analysis. 2 14 cases excluded from analysis because of nonresponse or don’t know response. 3 93 cases excluded from analysis due to missing response. 4 102 cases excluded from analysis due to missing response. 5 107 cases excluded from analysis due to missing response.

27

6 POSTNATAL CARE

This section presents the results for determinants analysis for PNC check-up using 2016 NDHS data,

starting with the proportion of women with a PNC check-up within 7 days by background and other

independent variables followed by predictors of PNC check-up within 7 days.

6.1 Women with a PNC Check-up within 7 Days by Background and Contextual Characteristics

Table 8 presents the proportion of women who had at least one PNC check-up within 7 days of their

last childbirth by background characteristics. The proportion of women who had a PNC check-up was

the highest (57%) among mothers age 20-24 at the time of last birth, followed by 54% among those age

15-19, 55% among those age 25-29, and 48% among those between age 30-49.

Figure 11 Postnatal check-up by household wealth quintile, Nepal DHS 2016

The utilization of PNC services was the highest among women with higher education (78%), with only

about 37% of women with no education having had a PNC check-up within 7 days (Table 8). With

caste/ethnicity, the percentage of women with a PNC check-up ranged from 41% (other Terai caste

groups) to 66% among the Brahmin/Chhetri (Table 8). Similar to women’s education, the proportion of

women with a PNC check-up was the highest among women whose husband had higher education

(67%) (Table 8). The proportion was the highest (78%) among women in the richest wealth quintile,

with the proportion as low as 36% among those in the poorest wealth quintile (Table 8, Figure 11). With

place of residence, the percentage of PNC check-ups was slightly higher (58%) among urban women

than rural women (Table 8). In relation to geographical differences, the proportion of women with a

PNC check-up ranged from as low as 34% in Province 6 (Karnali Province) to 72% in Province 4,

Gandaki Province (Table 8, Figure 12).

36.3

50.7

54.6

63.3

78.3

54.5

0

10

20

30

40

50

60

70

80

90

100


pe

rce

nta

ge


*** p<0.001; ** p<0.01; * p<0.05

28

Figure 12 Postnatal check-up by province, Nepal DHS 2016

61.5

39.0

64.5

71.9

57.0

33.9

58.2

54.5

0

10

20

30

40

50

60

70

80

90

100


Pe

rce

nta

ge

Province***

*** p<0.001; ** p<0.01; * p<0.05

29

Table 8 Percentage of women with a postnatal check-up within 7 days of delivery, among women with a live birth in the past 2 years, by background characteristics, Nepal DHS 2016



15-19 53.7 149 44.6-62.5 20-24 57.3 259 49.4-64.8 25-29 55.2 197 47.6-62.6 30-49 47.7 113 34.6-61.0

Education


Caste/ethnicity1

Dalits 56.8 119 45.2-67.7 Muslim 42.6 42 22.2-65.8 Janajati 54.6 227 46.8-62.1 Other Terai 41.3 94 29.8-53.8 Brahmin/Chhetri 65.6 232 58.0-72.5





Place of residence

Rural 51.1 331 44.1-58.0 Urban 58.2 387 52.4-63.8

Province


Total 54.5 718 50.1-58.9

1 4 cases in “other” category excluded from analysis 2 14 cases excluded from analysis because of nonresponse or don’t know response

6.2 Women with a PNC Check-up within 7 Days by Other Variables (Health Care Access, Women’s Characteristics)

Table 9 presents the proportion of women who had at least one PNC check-up within 7 days of their

last child’s birth by access-related variables. The proportion of women with a PNC check-up was 71%

among those exposed to at least two health programs in the media, compared to those with fewer than

two or no media exposures (46%). The proportion of women with PNC check-ups varied slightly by

the distance to the health facility, with 59% among women with less than 30 minutes distance to health

facility as compared to those with more than 30 minutes (45%). Problems in health care access were

measured by how women perceive the five different dimensions: obtaining permission to seek treatment

(medical help), obtaining money needed for treatment, distance to health facility, not wanting to go

alone to the health facility, and concern about not having a female health provider. A substantial

proportion of women (69%) who had no problem in the five specified dimensions of problems in health

care access had a PNC check-up within 7 days in comparison to about 48% among those to whom all

five aspects were a problem.

30

Table 9 Percentage of women with a postnatal check-up within 7 days of delivery, among women with a live birth in the past 2 years, by additional characteristics, Nepal DHS 2016




No 45.8 457 39.9-51.9 Yes 71.4 261 64.7-77.3


>30 mins 44.9 247 37.0-53.2 <30 mins 59.0 471 53.6-64.3

Problem in health care access All 47.6 153 38.0-57.3 Some 53.7 459 48.2-59.0 None 68.9 106 57.5-78.3


Birth order number

3+ 40.5 235 32.0-49.5 1 66.0 272 59.3-72.1 2 52.5 211 45.3-59.5

Wanted pregnancy

No 55.8 151 46.1-65.0 Yes 54.2 567 49.0-59.3

4 ANC visits per protocol1

Not completed as per protocol 38.8 295 32.3-45.8 Completed as per protocol 68.2 389 62.0-73.9

Place of delivery2

Home 13.1 261 9.3-18.1 Institution 80.0 428 74.7-84.4

Sex of baby3

Girl 49.6 334 43.3-56.0 Boy 60.8 365 54.5-66.7

Advised PNC check-up4

No 40.2 273 33.8-46.9 Yes 67.5 410 61.5-73.0



No 52.8 413 46.7-58.8 Yes 58.9 279 51.5-65.9

Domestic violence

Yes 45.6 115 35.0-56.6 No 56.4 603 51.6-61.1

Total 54.5 718 50.1-58.9

1 34 cases excluded from analysis due to missing response 2 29 cases in categories such as “out of country” and “others” as place of delivery were excluded from analysis. 3 19 cases excluded from analysis due to missing response 4 35 cases excluded from analysis due to missing response 5 26 cases excluded from analysis due to missing response

With pregnancy-related characteristics (Table 9), the proportion of women with PNC check-ups

decreased with birth order from 66% among women with their last child as first birth to 41% among

women with third or higher-order births. The PNC check-up was not different by the women’s desire

to have their last pregnancy, but was higher (68%) among women who completed four ANC visits per

protocol.

31

Figure 13 Postnatal check-up by place of delivery, Nepal DHS 2016

The percentage of women with a PNC check-up was higher (80%) among women who had an

institutional delivery compared to those with a home delivery (13%) (Table 9, Figure 13). By sex of

child, 61% of women who had a boy as their last child had a PNC check-up in comparison to 50% for

women with a baby girl (Table 9). The proportion of PNC check-ups was higher (68%) among women

who were advised about PNC check-ups during their pregnancy, while it was 40% among those who

were not advised (Table 9, Figure 14).

13.1

80.0

54.5

0

10

20

30

40

50

60

70

80

90

100

Home/other Health Facility Total

Pe

rce

nta

ge

Place of Delivery***

*** p<0.001; ** p<0.01; * p<0.05

32

Figure 14 Postnatal check-up by advice for postnatal check-up, Nepal DHS 2016

The 2016 NDHS measured women’s empowerment by three characteristics: if women can refuse sex,

if they can decide on their own health care, and if they can decide to use contraception on their own.

With women’s empowerment, we found that the proportion of PNC check-ups was slightly higher

(59%) among empowered women (Table 9). Similarly, among women who didn't face domestic

violence (emotional, physical, or sexual violence), we found a slightly higher proportion (56%) of PNC

check-ups than with the women who faced domestic violence (46%) (Table 9).

6.3 Determinants of PNC Check-up within 7 Days

Table 10 presents the results on bivariate and multivariate binary logistic regression that illustrates the

odds of women having had a PNC check-up within 7 days of delivering their last child. After an initial

bivariate logistic regression, a multivariate logistic regression was used to adjust the effects of

covariates and the results presented in the table. The odds of PNC check-ups were nearly three times

higher among women from middle (aOR=2.67; 95% CI=1.21-5.88) and richer (aOR=2.95; 95% CI=

1.22-7.13) wealth quintile compared to women in the poorest wealth quintile. Surprisingly, women from

the urban areas had lower odds of having had a PNC check-up than those from the rural areas, although

this finding was marginally significant. Women from Province 1 had three and one-half times

(aOR=3.60; 95% CI=1.35-9.59) higher odds of having had a PNC check-up as compared to women

from Province 6 (Karnali Province). The odds of a PNC check-up were nearly 30 times higher

(aOR=30.08; 95% CI=15.56-58.12) among women who delivered their child at a health facility as

compared to women with a home delivery. Women who were advised about a PNC check-up had more

than two and one-half times higher odds (aOR=2.62; 95% CI=1.50-4.59) of having had a PNC check-

up as compared to those who were not advised.

40.2

67.5

54.5

0

10

20

30

40

50

60

70

80

90

100

No Yes Total

Pe

rce

nta

ge

Birth preparedness***

*** p<0.001; ** p<0.01; * p<0.05

33

Table 10 Logistic regression of women with a postnatal check-up within 7 days of delivery, among women with a live birth in the past 2 years, Nepal DHS 2016


Background variables


30-49 149 Ref Ref 15-19 259 1.27 0.65-2.48 0.86 0.28-2.61 20-24 197 1.47 0.78-2.76 1.18 0.46-3.05 25-29 113 1.35 0.74-2.47 0.93 0.40-2.19

Education

No education 219 Ref Ref Basic education 336 2.03** 1.32-3.11 1.48 0.78-2.81 Higher education 163 5.98*** 3.27-10.94 3.06 0.85-10.95

Caste/ethnicity1

Dalits 119 Ref Ref Muslim 42 0.56 0.20-1.60 0.75 0.27-2.04 Janajati 227 0.91 0.51-1.63 0.90 0.43-1.89 Other Terai 94 0.53 0.27-1.07 0.60 0.21-1.76 Brahmin/Chhetri 232 1.45 0.80-2.62 1.51 0.71-3.23

Husband's education

No education 102 Ref Ref Basic education 398 1.75 0.97-3.15 0.52 0.25-1.09 Higher education 218 3.37*** 1.75-6.48 0.60 0.19-1.86


Poorest 197 Ref Ref Poorer 161 1.80* 1.09-2.98 1.98 0.92-4.29 Middle 148 2.11** 1.30-3.43 2.67* 1.22-5.88 Richer 134 3.02*** 1.67-5.47 2.95* 1.22-7.14 Richest 78 6.33*** 2.77-14.47 1.82 0.52-6.44

Place of residence

Rural 331 Ref Ref Urban 387 1.33 0.92-1.93 0.52* 0.31-0.89

Province

Province 6 112 Ref Ref Province 1 124 3.11*** 1.76-5.50 3.60* 1.35-9.59 Province 2 75 1.25 0.72-2.17 1.70 0.51-5.61 Province 3 81 3.55*** 1.87-6.73 2.06 0.67-6.36 Province 4 119 4.98*** 2.52-9.83 2.08 0.58-7.48 Province 5 119 2.58** 1.40-4.76 2.00 0.69-5.81 Province 7 88 2.71** 1.37-5.36 0.84 0.30-2.37



No 457 Ref Ref Yes 261 2.96*** 1.95-4.49 1.11 0.56-2.21


>30 mins 247 Ref Ref <30 mins 471 1.77** 1.17-2.68 0.75 0.39-1.44


All 153 Ref Ref Some 459 1.28 0.81-2.01 0.83 0.32-2.11 None 106 2.44** 1.32-4.50 0.74 0.38-1.47

(Continued…)

34

Table 10—Continued



Birth order number

3+ 235 Ref Ref 1 272 2.86*** 1.79-4.58 0.72 0.30-1.74 2 211 1.62* 1.04-2.52 0.97 0.46-2.05

Wanted pregnancy

No 151 Ref Ref Yes 567 0.94 0.60-1.46 0.60 0.31-1.17

4 ANC visits per protocol2

Not completed per protocol 295 Ref Ref All ANC visits as specified 389 3.38*** 2.24-5.10 1.77 0.97-3.23

Place of delivery3

Home 261 Ref Ref Institution 428 26.44*** 15.98-43.74 30.08*** 15.56-58.12***

Sex of baby4

Girl 334 Ref Ref Boy 365 1.57* 1.09-2.27 1.02 0.57-1.82

Advised PNC check-up5

No 273 Ref Ref Yes 410 3.10*** 2.12-4.52 2.62** 1.50-4.59**



No 413 Ref Ref Yes 279 1.28 0.85-1.92 0.69 0.36-1.33

Domestic violence

Yes 115 Ref Ref No 603 1.54 0.96-2.47 1.24 0.69-2.22

* p<0.05; ** p<0.01; *** p<0.001 1 4 cases falling to other category dropped from analysis. 2 34 cases falling short due to missing response. 3 29 cases falling short because some categories such as out of country and others as place of delivery were dropped. 4 19 cases falling short due to missing response. 5 35 cases falling short due to missing response. 6 26 cases falling short due to missing response.

35

7 DISCUSSION

This further analysis of the 2016 NDHS data focused on the determinants of three outcome variables of

interest in maternal health care utilization: ANC, institutional delivery, and PNC. In the determinants

analysis, four ANC visits as per national protocol, place of delivery, and PNC check-ups within 7 days

of delivery for the last pregnancy/last childbirth were the outcome variables. In addition to the

determinants analysis, we also assessed the change in prevalence between 2011 and 2016 of four or

more ANC visits (four ANC visits per protocol was not available in 2011 NDHS), place of delivery, and

PNC check-up within 7 days. Results indicate that there are substantial subgroup differences in the

prevalence of the three outcome variables and in some key determinants associated with those

outcomes. In addition, trend analysis of the three outcome variables shows some significant changes in

prevalence from 2011 to 2016.

7.1 Trends of Four ANC Visits, Institutional Delivery, and PNC Check-up within 7 Days

There has been a substantial increase from the 2011 to the 2016 NDHS in the proportion of pregnant

women who completed four or more ANC visits results, with the proportion nearly three-fourths in

2016 compared to just 56% in 2011. The proportion of institutional delivery also increased significantly,

with every two in five women giving birth to their last child in a health facility in 2011 compared to

three in five women in 2016. There was minimal progress in PNC check-ups within 7 days of delivery,

which only increased from 55% in 2011 to 58% 2016, and the change was not statistically significant.

This could be due to several factors including the initiation of the Aama program in 2009, which

included incentives for women who completed four ANC visits but not for PNC separately (Aryal and

Bhatt 2014).The safe motherhood program that was initiated in 1997 (Department of Health Services

2018) included an enhanced focus on behavior change communication (highlighted in the National

Communication Strategy for Maternal, Newborn and Child Health, 2011-2016), which could have

stimulated the increase in the utilization of maternal health care services. The National Safe Motherhood

and Neonatal Health Long Term Plan 2006-2017 aimed to socially empower individuals, groups, and

networks to practice safe motherhood and neonatal health behaviors, which could lead to increased

equity and access to health services. The plan also focused on enhanced, equitable provision of quality

maternal and neonatal health services by strengthening the supply-side environment (Family Health

Division 2006). Interventions guided by the plan could have helped to increase the utilization of

maternal health care services. Similarly, the Nepal Health Sector Programme-2 Implementation Plan

(NHSP2 IP) 2010-2015 aimed to increase the proportion of pregnant women who completed at least

four ANC visits to 80%, and institutional delivery to 40% by 2016. This was meant to strengthen and

expand maternal and newborn health care services with a major focus on the Aama program and its

integration with the incentive for four ANC visits (Ministry of Health and Population 2010). Service

delivery was guided by this sector strategy from 2010-2015, and could have helped to increase the

utilization of ANC visits and institutional delivery.

Although there is some progress in the utilization of maternal health care services, the path ahead for

increasing institutional delivery rate to 70% by 2020 (Ministry of Health and Population 2015) and 90%

by 2030 (National Planning Commission 2017), and four ANC visits and PNC check-ups to 90% by

2030 (National Planning Commission 2017), will not be easy. The stagnant MMR, which has remained

at 239 per 100,000 live births for the 7-year period before the 2016 NDHS (Ministry of Health, New

ERA, and ICF 2017), remains a concern. Reducing the MMR would require further improvement in

36

maternal health service utilization such as ANC visits, institutional delivery, and PNC check-ups. This

could be achieved through more focused interventions that target the underserved and most

marginalized population, as evidenced by our regression analyses.

7.2 Four ANC Visits

In the bivariate analysis, we found subgroup differences in the four ANC visits as per protocol.

However, in the multivariate analysis, wealth quintile, province, and birth order were the only variables

independently associated with four ANC visits.

By wealth quintile, our analysis showed that women in the richer wealth quintile had nearly twice higher

odds of completing the four ANC visits in the 4th, 6th, 8th, and 9th month of their last pregnancy. The

significant association of pregnant women in the richest wealth quintile completing the four ANC visits

in the bivariate analysis was not statistically significant after adjusting for the covariates. This could be

due to the small sample size in the richest group in comparison to other subgroups, and other reasons

not measured in the 2016 NDHS. The number of ANC visits remains low among the poorer group,

despite health sector efforts to improve maternal health status among the poor (Ministry of Health and

Population 2010) with government incentive schemes for those women who complete the ANC visits

and deliver their babies in a health facility (Aryal and Bhatt 2014).

Poorer women have other financial barriers. Research in other low- and middle-income countries such

as Nigeria show that acquiring money was one of the three major barriers for women, in addition to

long distance and unavailability of transport to ANC services (Fagbamigbe and Idemudia 2015).

Previous studies, including the 2011 NDHS results, show that the odds of completing four or more ANC

visits is higher among richer women (Pandey et al. 2013). This finding is supported by other small-

scale studies from Nepal, which found richer women had higher odds of using ANC services and higher

levels of autonomy associated with being a member of an advantaged ethnic group (Deo et al. 2015).

This suggests that poor economic status continues to be a barrier to utilizing ANC services in Nepal

because although ANC care is free, associated costs, for example those related to the travel to health

facilities, are barriers to ANC service utilization. We found that women in Provinces 4 and 7 performed

well with completing four ANC visits during their last pregnancy. The most recent annual report of the

Department of Health Services for the fiscal year 2016/17 also rated these provinces among the high-

performing provinces with completion of four ANC visits, although Province 3 ranked higher than

Provinces 4 and 7 (Department of Health Services 2018).

Our analysis indicates that there is a need for targeted interventions that can decrease the gap between

underperforming and well-performing provinces. The Human Development Index (HDI) in the western

hills and western mountains that was higher than the national average could have contributed to the

greater likelihood of women seeking care (National Planning Commission 2014). In a recently released

report from the National Planning Commission, nearly half of the population of Provinces 2 and 6 are

poor, according to the multidimensional poverty index (MPI), while Province 4 (Gandaki Province) has

one of the lowest scores (National Planning Commission & Oxford Poverty and Human Development

Initiative 2018). These findings further emphasize the importance of need-based interventions in

maternal health in provinces with a low HDI and high MPI index.

This study found that women are less likely to complete the four ANC visits with an increase in the

birth order. Women whose last pregnancy was first and second in order had higher odds of completing

four ANC visits. Women could perceive their first pregnancy as high risk and thus may seek more care

with their first pregnancy.

37

In addition, although this analysis did not find an association of ANC utilization with distance to health

facility, a study from the Banke District in Nepal has shown that shorter distance, low traveling cost,

and less waiting time were associated with four or more ANC visits (Paudel, Thepthien, and Hong

2016).

7.3 Institutional Delivery

The bivariate analysis of institutional delivery showed subgroup differences in a number of variables.

Basic and higher education; middle, richer, and richest wealth quintiles; residence in Provinces 4 and

7; completion of four ANC visits; and birth preparation were independently associated with institutional

delivery.

Most findings in this study concur with previous findings. For example, the further analyses of 2011

NDHS showed that better education and wealthier economic status are associated with higher

institutional delivery rates (Karkee, Lee, and Khanal 2014; Shahabuddin et al. 2017). The association

between education and health care behavior has been clearly demonstrated by other global studies that

found educated women to be more aware about safe delivery issues, have higher self-efficacy, and

exhibit better adherence to self-care and healthy behaviors (Zahodne et al. 2015). This analysis did not

demonstrate a significant association of husband’s education after adjusting the covariates, although

this factor was associated with health care behavior in the further analysis of the 2007 Bangladesh DHS

(Kamal, Hassan, and Alam 2015). The strong association of household wealth quintile with institutional

delivery shows that women could have been deprived of using health facilities for delivery due to their

poor wealth status. In an attempt to address this, the Government of Nepal through MoHP in its Aama

program has made the provision of transport incentives for those delivering in the health facility (Aryal

and Bhatt 2014), and this has been doubled since the beginning of the current fiscal year 2018/19

(Family Health Division 2018). However, there are no targeted programs yet specifically for the poorer

households.

Our analysis has shown a higher likelihood of institutional delivery in Provinces 4 and 7. The findings,

particularly in Province 7 (Sudurpashchim Province), concur with the recent annual report of DoHS

which showed that Province 7 is among the two provinces with much higher institutional delivery rates

compared to other provinces and the national average. However, Province 4 (Gandaki Province) had an

institutional delivery rate for 2016/17 of only 46%, which is much lower than the national average

(Department of Health Services 2018). Our study’s findings deviate slightly from those of the DoHS,

and the higher likelihood of institutional delivery observed in Province 4 (Gandaki Province) in our

study could also be linked to higher HDI in the western hills and western mountains than that of national

average (National Planning Commission 2014).

This analysis has shown that women who complete four ANC visits with birth preparedness were more

likely to have an institutional delivery. This finding is similar to the 2011 NDHS further analysis report,

which also showed significant association of four or more ANC visits and birth preparedness (Karkee,

Lee, and Khanal 2014). Timely contact of the pregnant women with the health care providers during

ANC visits could motivate women and help them understand the importance of delivering in a health

facility. Similarly, a woman who has made preparations (money saved, food ready, and clothes

available) for the delivery may be better motivated to have a facility delivery. Birth preparedness could

also be a result of regular contact with health workers during the ANC visits. It is likely that women

who complete ANC visits are encouraged to adopt effective measures for safe delivery. Thus, it appears

that the ANC visit and birth preparedness are related to choosing the place of delivery.

38

7.4 Postnatal Check-up

The prevalence of PNC check-ups within 7 days was different among several subgroups in the bivariate

analysis. A PNC check-up within 7 days is an important window of opportunity for assessing the mother

and newborn for health and other problems. Factors that affect PNC check-ups within 7 days include

wealth quintile, geography (provinces), and urban versus rural location. Women in the richer wealth

groups, those living in Province 1, and those residing in rural areas were more likely to have at least

one PNC check-up within 7 days.

Wealthier women are more likely to complete four ANC visits and to deliver in a health facility. Wealth

continues to be a significant determinant of PNC check-ups as well. The analysis also shows that women

delivering in a health facility and those who were advised about a PNC check-up were more likely to

have a PNC check-up within 7 days. This finding could be a result of interventions focused on

improving overall maternal health care as guided by the National Safe Motherhood and Newborn Health

Long Term Plan 2006 -2017. This plan aimed to empower individuals for safe motherhood and enhance

the equitable provision of maternal health services (Family Health Division 2006), and to increase

healthy practices and utilization of quality maternal health services (Ministry of Health and Population

2010). Our analysis has found that women who delivered in a health facility had very high odds of

having a PNC check-up within 7 days. It is possible that the contact with health care workers before

women are discharged from the health facility after the delivery could have contributed to a major

portion of PNC check-ups.

Our analysis also showed that women who reside in urban areas are less likely to have PNC check-ups

in comparison to rural women, although the findings were minimally significant. This could be related

to the active role of female community health volunteers (FCHVs) in the rural areas. More awareness,

information, education, and behavior change communication (IEC/BCC) interventions are needed to

increase women’s awareness of the importance of postnatal check-ups, although there may be other

factors that were not included in this study and may have affected the underutilization of PNC services

in urban areas.

7.5 Conclusion

Findings from the 2016 NDHS analysis of women’s maternal health care seeking found that every three

in five women completed four ANC visits per protocol, delivered their baby in a health facility, and had

a PNC check-up within 7 days of delivery. Four or more ANC visits increased by 15 percentage points

from 59% in 2011 to 74% in 2016. Compared to the 2011 NDHS, institutional delivery increased with

statistical significance by 21 percentage points in 2016, while the increase in the proportion of women

who had a PNC check-up within 7 days was very minimal with 3 percentage points and not statistically

significant.

Belonging to a richer wealth quintile, residing in provinces 4 and 7, and lower birth order were the only

variables independently associated with four ANC visits per protocol. Similarly, women’s education,

belonging to richer wealth quintile, living in Provinces 4 and 7, having completed four ANC visits per

protocol, and birth preparedness were independently associated with institutional delivery. Belonging

to the middle or richer wealth quintile, living in province 1, institutional delivery, and having had advice

about PNC check-ups were independently associated with PNC check-up within 7 days. Four ANC

visits per protocol predicted institutional delivery, and institutional delivery predicted PNC check-up,

indicating the completion of continuum of care. Province 2 appears to have performed poorly with

39

regard to four ANC visits per protocol, while Province 6 (Karnali Province) in particular has performed

poorly with institutional delivery and PNC check-up.

In summary, maternal health care utilization was better among women from richer wealth groups, those

with higher education, and those from Provinces 4 and 7. Outcomes such as institutional delivery and

PNC check-ups were dependent upon factors such as complete ANC check-ups as per protocol and birth

preparedness.

7.6 Recommendations and Policy Implications

Based on the results of this further analysis, common background characteristics such as improved

education level, improved socioeconomic status, belonging to advantaged ethnic groups, and living in

certain high-performing provinces with a higher HDI are associated with greater utilization of maternal

care services. It is clear that those who are marginalized are less likely to access maternal health care.

There is a need for government interventions that focus on broader social determinants of health that

can reduce equity gaps among different subgroups. Barriers such as obtaining permission to seek health

care and money for health care can be expected to improve with the improvement in educational and

socioeconomic status across all categories and geographies. In contrast, barriers such as unavailability

of a health facility within 30 minutes of distance and perceived barriers at the point-of-service utilization

such as the unavailability of female health care providers call for urgent action from the government at

all levels: federal, provincial, and local. We also found that certain factors have also positively affected

the outcomes, such as four ANC visits per protocol and birth preparedness that directly affect

institutional delivery, and advice to obtain PNC check-ups within 7 days. There is a need to sustain the

focus on these interventions and to increase access to these pre-interventions in order to achieve

improvements in outcome variables such as institutional delivery and PNC check-ups.

7.6.1 Policy level

• Federal and provincial governments must continue acting upon broader social determinants of

health such as improving the education and socioeconomic status of women.

• There is a need to develop and update policies and strategies that reduce the equity gap

among education levels, wealth quintile, and geographical disparities.

7.6.2 Program/implementation level

• Enhance efforts to increase ANC check-ups and the quality of ANC so that more women will

deliver their child in a health facility and attend timely PNC check-ups.

• Sustain and strengthen IEC and BCC so that more women will seek ANC, which will ensure

birth preparedness that encourages women to complete ANC visits per protocol and choose a

health facility for delivery of their child.

Ultimately, there is a need for generating more evidence on the barriers to utilizing ANC, institutional

delivery, and postnatal care.

41

REFERENCES

Aryal, S., and H. Bhatt. 2014 Aama Programme: A Programme for Nepali Women. Kathmandu,

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APPENDIX

Appendix Figure A1 Conceptual framework for analyzing determinants of place of delivery

Appendix Figure A2 Conceptual framework for analyzing determinants of PNC check-up within 7 days

Contextual factors

Geographical Regions (Province) Residence – urban rural



Enabling factors


Need factors

4 ANC visits as per protocolANC quality of careBirth preparedness

Place of Delivery

Contextual factors

Geographical Regions (Province) Residence – urban rural



Enabling factors


Need factors

Wanted pregnancyBirth order4 ANC visits as per protocolPlace of deliverySex of babyAdvised PNC check-up

PNC within 7 days

Documents

Maternal Health Care in Nepal: Trends and Determinants · 1 INTRODUCTION ... Institutional Delivery, and PNC Check-up within 7 ... Figure 2 Trends in four or more antenatal care visits,